Death and dying in Brazilian medical training: an integrative review

Melo, Vinícius Leite; Maia, César Quadros; Alkmim, Elisa Maia; Ravasio, Amanda Pais; Donadeli, Rafael Lourenço; Paula, Larissa Ottoni Estevanin de; Silva, Alexandre Ernesto; Guimarães, Denise Alves

doi:10.1590/1983-80422022302526EN

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Research • Rev. Bioét. 30 (2) • Apr-Jun 2022 • https://doi.org/10.1590/1983-80422022302526EN copy

Death and dying in Brazilian medical training: an integrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

To describe how death and dying are approached in the medical undergraduate programs in Brazil and their repercussions for students, an integrative review of publications from 2008 to 2019 was carried out, resulting in a selection of 36 articles. The difficulties in approaching the theme related to the biomedical model of training, the organization of the curriculum, and the training of teacher were identified. Those affect students, causing psychic suffering and hindering the training process. Few curriculums approach psychosocial aspects related to death and dying, which are often approached for insufficient credit hours, inadequate methods, or as extracurricular activities. Solution proposals point to the necessity of investments in palliative care in the undergraduate programs. In conclusion, these themes need to be more thoroughly included in the National Curricular Directives of medicine programs, to foster a more humanitarian training, based on ethical principles, and which prepares students and professionals to deal with end-of-life situations

Education, medical; Death; Mental health

Author(s)	Journal and year of publication	Sample characteristic/place of research (state)/ course year/age group	Method
Sadala and Silva¹⁸	Interface (Botucatu) , 2008	24 undergraduate medical students, São Paulo 5th- and 6th-year students who had experienced two or three situations involving caring for terminally ill patients Age range between 21 and 27 years old	Qualitative and descriptive
Quintana and collaborators¹⁹	Revista Brasileira de Educação Médica , 2008	11 undergraduate medical students, Rio Grande do Sul 1st-to-5th-period students Age range between 18 and 27 years old	Qualitative, ethnographic
Brito and collaborators²⁰	Revista Paraense de Medicina , 2008	240 undergraduate medical students, Pará 1st to 4th year students Age range between 17 and 33 years old	Quantitative, cross-sectional study
Falcão and Mendonça²¹	Revista Brasileira de Educação Médica , 2009	48 medical professors, Rio de Janeiro Unspecified age group	Qualitative and reflexive
Marta and collaborators²²	Revista Brasileira de Educação Médica , 2009	120 residents and 100 undergraduate medical students, São Paulo 3rd year students and residents Unspecified age group	Quantitative, cross-sectional study
Mascia and collaborators²³	Revista Brasileira de Educação Médica , 2009	82 undergraduate medical students, São Paulo 41 from the 6th year and 41 from the 2nd year Unspecified age group	Quantitative, cross-sectional study
Bifulco and Iochida²⁴	Revista Brasileira de Educação Médica , 2009	15 health professionals, including three physicians, São Paulo Mean age group of 35.7 years, age range between 22 and 80 years old	Qualitative, descriptive, exploratory
Silva and Ayres²⁵	Revista Brasileira de Educação Médica , 2010	15 undergraduate medical students and four residents, Rio Grande do Sul At least one student from each period and two from each year of residency (R1 and R2) Unspecified age group	Qualitative and reflexive
Combinato and Queiroz²⁶	Ciência & Saúde Coletiva , 2011	Six physicians and seven nurses, São Paulo Age range between 24 and 48 years old	Qualitative, exploratory
Andrade and collaborators²⁷	Revista Brasileira de Educação Médica , 2011	120 undergraduate medical students, Federal District 25% of students in each year (1st to 6th year) Age range between 18 and 31 years old	Qualitative, quantitative, cross-sectional, descriptive study
Pinheiro and collaborators²⁸	Revista Brasileira de Educação Médica , 2011	180 undergraduate medical students, São Paulo 1st to 6th-year students Unspecified age group	Quantitative, cross-sectional study
Azeredo, Rocha, and Carvalho²⁹	Revista Brasileira de Educação Médica , 2011	Five undergraduate medical students, Rio Grande do Sul 9th to 12th-period students Unspecified age group	Qualitative, descriptive, exploratory
Pinheiro, Benedetto, and Blasco³⁰	Revista Brasileira de Medicina , 2011	Unspecified sample, São Paulo Undergraduate medical students and residents 6th year students and residents Unspecified age group	Qualitative, participant observation
Borges and Mendes³¹	Revista Brasileira de Enfermagem , 2012	One nutritionist, two nurses and two physicians, Federal District Age range between 26 and 32 years old	Qualitative, descriptive, exploratory
Santos, Menezes, and Gradvohl³²	Ciência & Saúde Coletiva , 2013	Six undergraduate medical students, 10 undergraduate nursing students and six undergraduate psychology students, São Paulo Unspecified course period Unspecified age group	Qualitative, descriptive, exploratory
Figueiredo and Stano³³	Revista Brasileira de Educação Médica , 2013	Unspecified sample 2nd year undergraduate medical students Age group above 16 years	Qualitative and reflexive
Almeida and Falcão³⁴	Revista Brasileira de Educação Médica , 2013	27 physicians, Rio de Janeiro Unspecified age group	Qualitative and reflexive
Poletto, Santin, and Bettinelli³⁵	Revista Brasileira de Educação Médica , 2013	11 physicians treating older patients, Rio Grande do Sul Age range between 39 and 63 years old	Qualitative and exploratory
Bertoldi, Folberg, and Manfroi³⁶	Revista Brasileira de Educação Médica , 2013	Undergraduate medical students, Rio Grande do Sul Unspecified sample Unspecified age group	Qualitative, case study
Fonseca and Geovanini³⁷	Revista Brasileira de Educação Médica , 2013	Seven undergraduate medical students, one PhD student in geriatrics and one not identified, Rio de Janeiro Unspecified course period Average age group of 27 years	Qualitative, exploratory
Silva, Leão, and Pereira³⁸	Revista Bioética , 2013	76 undergraduate medical students, Pernambuco 3^rdperiod students Unspecified age group	Qualitative and reflexive
Andrade and collaborators³⁹	Revista Brasileira de Educação Médica , 2014	40 undergraduate medical students, Ceará 2nd to 6th year students Average age group of 21.5 years in one group and 21 years in the other	Qualitative, quantitative, longitudinal, descriptive
Duarte, Almeida, and Popim⁴⁰	Interface (Botucatu) , 2015	26 undergraduate medical students, São Paulo 4th and 6th period students Unspecified age group	Qualitative, descriptive
Costa, Poles, and Silva⁴¹	Interface (Botucatu) , 2016	10 students, five from medicine and five from nursing, Minas Gerais 3rd to 9th period undergraduate students Age range between 21 and 30 years old	Qualitative, descriptive, exploratory
Silva and collaborators⁴²	Revista Brasileira de Educação Médica , 2016	25 undergraduate medical students, 83 medical professors and 64 residents, Rio Grande do Norte 12th period students, and physicians Unspecified age group	Quantitative, cross-sectional study
Alves and collaborators⁴³	Revista da Associação Médica Brasileira , 2017	69 undergraduate medical students, Sergipe 9th to 12th period students Average age group of 25.1 years	Quantitative, cross-sectional study
Freitas and collaborators¹²	Revista Bioética , 2017	23 undergraduate medical students, Bahia Unspecified course period Unspecified age group	Qualitative, descriptive
Tamada and collaborators⁴⁴	Revista de Medicina , 2017	Nine physicians, São Paulo Age range between 32 and 58 years old	Qualitative, descriptive, cross-sectional
Storarri and collaborators⁴⁵	BMJ Supportive e Palliative Care , 2017	293 undergraduate medical students and 43 residents, São Paulo 1st to 6th year students and residents Unspecified age group	Qualitative, descriptive
Santos, Lins, and Menezes⁴⁶	Revista Bioética , 2018	47 undergraduate medical students, Bahia 1st year students Unspecified age group	Qualitative, descriptive
Correia and collaborators⁴⁷	Revista Brasileira de Educação Médica , 2018	134 undergraduate medical students, Alagoas 9th to 12th period students Age range between 22 and 37 years old	Qualitative, descriptive, cross-sectional
Malta, Rodrigues, and Priolli⁴⁸	Revista Brasileira de Educação Médica , 2018	240 undergraduate medical students, São Paulo Unspecified course period Age group above 19 years	Quantitative, cohort
Pereira, Rangel, and Giffoni⁴⁹	Revista Brasileira de Educação Médica , 2019	81 undergraduate medical students, Goiás 6th year students Age group above 18 years	Qualitative, quantitative, descriptive, evaluative
Marques and collaborators⁵⁰	Revista Brasileira de Educação Médica , 2019	66 undergraduate medical students, Acre 8th-and 11th-period students Average age group of 26.76 years	Qualitative, quantitative, descriptive, evaluative
Santos and Pintarelli⁵¹	Revista Brasileira de Educação Médica , 2019	805 undergraduate medical students and 93 residents, Paraná All-period students Age range between 18 and 22 years among students and between 23 and 27 years among residents	Quantitative, observational
Meireles and collaborators⁵²	Revista Bioética , 2019	51 undergraduate medical students and 42 physicians, Minas Gerais 2nd and 4th period students Age group equal or greater than 18 years	Qualitative, descriptive, cross-sectional

Authors	Main results	Main recommendations
Sadala and Silva¹⁸	Anxiety in treating terminal patients and difficulty coping with their own feelings; impotence, depression and anxiety in the face of death; deficient training and unpreparedness to address terminality; distancing from the patient	Broaden the approach towards aspects related to terminality in medical education, such as interpersonal skills, ethics, and medical deontology
Quintana and collaborators¹⁹	Anguish in the face of terminality; pain and suffering regarding training models and practices	Create spaces to discuss the topic and share experiences
Brito and collaborators²⁰	Anxiety in the face of death; distancing from the patient and professional dehumanization; poor curriculum organization; own health concerns	Encourage the development of interpersonal skills in students; search for a greater humanization in medical education, so that illness and death can be better coped with
Falcão and Mendonça²¹	Suffering and unpreparedness of physicians, students, and patients in the face of death; lack of emotional support during undergraduate studies; poor curriculum organization; predominance of the biomedical perspective	Create spaces to discuss the topic and share experiences
Marta and collaborators²²	Development of burnout syndrome; distancing from and indifference towards the patient; poor curriculum organization; perceived theoretical, practical, and individual preparation to cope with death and dying during undergraduate studies	Include a theoretical-practical approach to terminality, provide thanatology courses
Mascia and collaborators²³	Psychic suffering in the face of terminality; different perceptions and reactions between students from different periods in the face of death	Include thanatology courses throughout medical education; discuss clinical cases; create spaces for discussion; offer psycho-pedagogical support
Bifulco and Iochida²⁴	Psychic suffering, frustration and sense of loss; education focused on the biomedical model; perceived lack of the topic of death during training	Discuss death and dying throughout the undergraduate course, especially when training in palliative care; encourage the development of empathy and user embracement skills
Silva and Ayres²⁵	Vulnerabilities and unpreparedness to address terminality situations; deficient approach to the topic; lack of contact with death throughout the course; deprivation of contact with patients in the first years	Incorporate specific content and active and diversified methods to address suffering and terminality; experience terminality throughout the course; develop psychosocial aspects and the communication process; provide institutional psycho-pedagogical support
Combinato and Queiroz²⁶	Unpreparedness to cope with terminality situations; training focused on the biomedical and scientific model; manifestation of negative feelings related to terminality	Change the training perspective, focusing more on terminality issues; need to develop empathy, user embracement and dialogue skills
Andrade and collaborators²⁷	Recognition of the development of positive attitudes and maturity regarding issues related to death; better understanding of the illness and terminality process	Develop empathy, user embracement and dialogue skills; involve oneself in care when cure is not possible; use active methodologies
Pinheiro and collaborators²⁸	Poor approach to terminality and lack of knowledge regarding bioethical concepts related to moral types of death (euthanasia, dysthanasia, and orthothanasia)	Develop theoretical and practical knowledge on terminality and bioethical concepts
Azeredo, Rocha, and Carvalho²⁹	Psychic suffering and impotence; little approach to the topic; feeling of unpreparedness, and distancing from the patient	Provide experiences related to terminality throughout the course; develop theoretical and practical knowledge on terminality; develop psychosocial aspects related to illness and terminality; provide institutional psycho-pedagogical support
Pinheiro, Benedetto, and Blasco³⁰	Unpreparedness to address terminality situations throughout the course; death seen as medical failure; active methodologies improved communication and expressing feelings	Invest in palliative care education; provide practical experiences during the training process; develop theoretical and practical knowledge on terminality in each curricular subject
Borges and Mendes³¹	Distancing from the patient; curriculum approach with poor focus on aspects related to terminality	Develop interpersonal skills of empathy, user embracement and dialogue ; be involved in the care process in terminal situations
Santos, Menezes, and Gradvohl³²	Unpreparedness to deal with death; psychic suffering; poor approach by the mandatory curriculum; ignorance of the term “orthothanasia”	Provide an education that develops psychosocial and communication aspects regarding death
Figueiredo and Stano³³	Importance of using active teaching methodologies and curricular subjects that address death; importance of thanatology and palliative care subjects	Encourage the development of interpersonal skills by subjects with active methodologies
Almeida and Falcão³⁴	Limits of medical action in the face of death in the ICU; unpreparedness in medical training to cope with terminal situations; recognition of the need for psychological support	Implement a thanatology course; student must witness moments of terminality during undergraduate studies; create spaces for discussion
Poletto, Santin, and Bettinelli³⁵	Need for further discussions and reflections on the approach to death and dying in academic education; death and dying are not included in the pedagogical projects; concern for patients and families	Implement a thanatology course; create spaces to share emotions and knowledge
Bertoldi, Folberg, and Manfroi³⁶	Contact with patient death and suffering generates fear; discouragement to seeking knowledge, and difficulty perceiving oneself and others	Does not provide recommendations
Fonseca and Geovanini³⁷	Death as an indicative of medical failure; student unpreparedness to address terminality; approach to death and dying considered deficient in the curriculum; some students feel prepared to cope with death	Include the topic of palliative care in the medical course; develop interpersonal relationships and communication skills; provide pedagogical support
Silva, Leão, and Pereira³⁸	Importance of using bioethical teaching in the medical course; perceived primacy of the curative perspective on medicine; deficient curricular organization on aspects related to terminality	Include subjects focused on terminality and new teaching methodologies
Andrade and collaborators³⁹	Education that barely addresses death and dying; student anguish over terminal and cadaver contact in anatomy classes; psychic suffering related to contact with death (anxiety, depression, insomnia)	Expand the approach to terminality throughout the course by creating spaces for discussion; provide psycho-pedagogical support
Duarte, Almeida, and Popim⁴⁰	Death seen as a medical failure; psychological distress among students in the face of death (feelings of failure, impotence, and anguish); feeling of unpreparedness, despite the progressive contact with the topic of terminality during undergraduate studies (insufficient workload, punctual approach)	Include a comprehensive approach to the topic of palliative care throughout the undergraduate course; provide in-person contact with terminality situations
Costa, Poles, and Silva⁴¹	Death seen as a medical failure; development of defense mechanisms (distancing from the patient); unpreparedness in training; poor approach by the mandatory curriculum	Encourage theoretical-practical palliative care education and research aimed at improving this training
Silva and collaborators⁴²	Poor approach to the topic of terminality and on completing the death certificate	Develop an approach that allows proper completion of the death certificate
Alves and collaborators⁴³	Psychic suffering in the face of terminality; feeling of failure, difficulty communicating with patients and their families	Create of spaces to discuss the topic
Freitas and collaborators¹²	Poor curricular organization to address terminality; students’ unpreparedness to deal with death; changes in the perception of death; new paradigm proposed by palliative care	Include mandatory thanatology subjects in the curriculum
Tamada and collaborators⁴⁴	Unpreparedness to address death; insufficient approach to the topic in the curriculum	Adopt active strategies and methodologies to approach topics related to terminality (cinema, psychodrama, role-playing, and workshops)
Storarri and collaborators⁴⁵	Unpreparedness to address terminality situations; lack of approach to communicating difficult news	Include the topic of palliative care in the undergraduate course; develop theoretical-practical activities on terminality
Santos, Lins, and Menezes⁴⁶	Understanding of death as a natural and social phenomenon; ethical and psychological aspects of death should be considered in medical practice; death seen as an enemy in medical practice, but also represents relief; need to replace the biomedical model and to broaden the approach to terminality in undergraduate studies	Develop interpersonal skills of empathy, user embracement and dialogue
Correia and collaborators⁴⁷	Death seen as medical failure; feelings of frustration when addressing the issue; anguish due to contact with a terminal patient; insufficient approach; lack of approach to communicating difficult news	Include thanatology courses as a curricular subject
Malta, Rodrigues, and Priolli⁴⁸	Unpreparedness to deal with terminality situations; student difficulty in communicating with patients and their families; advantages in acquiring knowledge for students who studied the topic throughout the undergraduate course	Develop interpersonal skills of empathy, user embracement and dialogue and therapeutic practices for pain control; provide a more humanized care to patients
Pereira, Rangel, and Giffoni⁴⁹	Feelings of anxiety and threat to their own life; poor approach to palliative care, orthothanasia, dysthanasia, and euthanasia by the curriculum; unpreparedness to address terminality	Include elective courses and extension projects on the subject; invest in palliative care education; provide a more humanized care to patients
Marques and collaborators⁵⁰	Undergraduate program based on the biological model; interference of past experiences and personal factors in the perception of death and dying	Offer opportunities for students to witness moments of terminality throughout the undergraduate course; create spaces to discuss the topic
Santos and Pintarelli⁵¹	Feelings of frustration, anxiety and helplessness in the face of terminality; insufficiency of the approach during undergraduate studies and contact with the subject restricted to the last years of the course	Expand the approach to the topic throughout the course
Meireles and collaborators⁵²	Unpreparedness to cope with terminality situations; deficient training; distancing from the patient	Include thanatology courses; develop theoretical-practical activities on terminality

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[1] Correspondence: Vinícius Leite Melo – Rua Sergipe, 771, ap. 401, Centro CEP 35500-012. Divinópolis/MG, Brasil.